Medical home model takes case management to the next level
CMs in physician offices coordinate care for chronically ill patients
Following the success of a 30-month pilot project with three primary care practices, Capital District Physicians' Health Plan (CDPHP) has expanded its medical home initiative to include an additional 21 physician practices.
The initiative places health plan case managers in primary care practices where they partner with the physicians to coordinate care for chronically ill and at-risk patients and help them understand how they can better self-manage their illness.
Preliminary data suggest that the pilot project is demonstrating improvements in quality and efficiency of health care by transforming the way primary care is practiced and reimbursed, says Lisa Sasko, MBA, director, clinical transformation for the Albany, NY-based health plan.
"We saw this as an opportunity to take case management to the next level in the medical home model. The goals of our case managers include identifying and working with high-risk chronically ill members who need better assistance coordinating their care, and there's no better way to do it than to partner with their physicians," says Charlene Schlude, RN, CCM, manager of case and disease management for the physician-based not-for-profit, individual practice association (IPA) model HMO.
The case managers are CDPHP employees and go to the physician offices to work directly with the patients, the physicians, and the office staff.
"It's not only important to work with physicians. The case managers need to build a rapport with the nurses, the schedulers, and other staff," Schlude says.
The case managers meet with the patients when they have physician appointments and make follow-up telephone calls as needed.
Telephonic case management will always have its place at the health plan, but face-to-face contact and building relationships work much better with the chronically ill population, Schlude says.
"Embedding health plan case managers in the physician office accomplishes many things. It increases the engagement rate, even if the case manager is calling over the telephone because the telephonic ID tells the patients the physician office is calling. The patients see the case managers as part of the practice and as being involved in the physician's plan of care," says Tracy Langlais, RN, vice president of resource coordination for CDPHP.
Because they are located in the physician's office, the case managers often can identify people with chronic diseases when they are first diagnosed and start working with them before the claims come in, she adds.
"A lot of times, physicians see patients in the treatment room and literally walk them down the hall to the case manager. This happens not just with the newly diagnosed but those who have been chronically ill for a long time who need help with adherence or social issues. Being on site helps us start the interventions earlier," Langlais says.
The nurses work with the physicians at the practice to identify patients who could benefit from their services and use the health plan's predictive modeling tool to look for patients at high risk. Other patients are found by the health plan's algorithm that identifies patients with gaps in care and by health plan nurses who work with health plan patients in local hospitals.
Each week, the case managers review the list of patients who have appointments the next week, access their electronic medical records, and work with the physicians to determine who they need to see.
"Having a case manager working with members face-to-face in their doctor's office helps improve their quality of life while helping them understand that the health plan is aligned with the physicians in ensuring that they get optimum care. With all the concerns about health care reform, this gives a solid message that their health plan wants to do the right thing for them. One of our goals in care management is to continue to send that message," Schlude says.
The embedded case managers are highly experienced case managers who understand the case management process.
"The clear reason we're in the physicians' office is that we know this population needs a lot of help. That is the role we set for the case managers, and we make sure all of them have a strong understanding of the goals we are trying to achieve and are able to communicate the goals to the physicians," Schlude says.
The nurse-to-patient ratio depends on the acuity of patients in the practice. Practices that have a lot of chronically ill members need more support, Schlude says.
"We want to make sure that the nurses have a caseload that is appropriate and that they are very careful in selecting the right population to work with. We also work with the nurses to help them understand that while they are part of the practice, their job is to coordinate care and not to do tasks like checking vital signs or putting patients in the treatment rooms," Schlude adds.
Case managers are assigned to the physician offices based on the size of the practice and the acuity of the patients and may cover more than one practice.
They have the flexibility to arrange their schedule at each practice around the days that the most chronically ill patients will be coming in.
The embedded case managers spend at least one day a week at the health plan offices.
They make follow-up calls to the patients when they are in the physician office as well as during the days they spend at the health plan.
When patients need additional help, the embedded case managers have the knowledge about other health plan resources and can reach out to their colleagues for assistance.
For instance, if patients have behavioral health issues or problems with understanding multiple medications, the case manager can get the health plan's behavioral health component or health plan pharmacists involved. If a patient has a lot of social issues, he or she can collaborate with the social worker on the team to see that the patient's needs are met.
"Our case management documentation system has the transparency to allow the other team members to share information and collaborate to ensure each member's needs are met," Schlude says.
The medical home initiative has two components practice transformation and payment reform, Sasko says.
The CDPHP patient-centered medical home pilot was launched in 2007 to address the national and regional primary care crisis and transform primary care practice and payment in the health's plan's area, Sasko says.
"The CDPHP board of directors and senior leadership recognized the need to pay primary care physicians differently, to make it a more attractive option for physicians of the future, and to support the practice in its transformation to medical home with the goal of improving quality and efficiency, ultimately increasing health care value," Sasko says.
The team researched what it would take to make a primary care physician's salary a more attractive option. Community research suggested an additional $85,000 would enhance the salary to a level that would make it a competitive option for medical students, she adds.
"The CDPHP payment model is a risk-adjusted capitation model with the opportunity for significant bonus earnings ($50,000 per physician) and stipend dollars ($35,000 per doctor) to support the practices' ongoing work to transform the way in which they deliver care. One of the goals for each practice is to become certified as a NCQA Level 3 Certified Medical Home," she says.
"We knew that the best way to create savings in the long term is to improve quality of care and improve efficiency through lower inappropriate utilization of the emergency room and hospital. We knew that in order to do that, we would have to incorporate case management into the practice," she says.
The health plan initially hired a consulting firm to bridge the gap between the health plan and the physician practices, then focused on integrating CDPHP resources into the practices.
"We realized that we have a lot of case management expertise and that we needed to take our resources outside of our four walls and get involved with the practices. After working with the consulting firm, the physicians saw that we were there to support them and were receptive to working with us directly," Sasko says.
Sasko and Schlude visited the three practices in the pilot in the spring of 2009 and discussed with them how the health plan could share its expertise.
"We informed them of all the services we provide here and showed them how they could fit into the practice. The physicians were receptive to case management services, and we worked with them on how we could best integrate our case managers into their practices," Schlude says.
The program has been a big success with everyone involved, Schlude says.
"The physicians like having a closer link with CDPHP's pharmacists and behavioral health team by having a person in the office who knows about the programs," Schlude says.
Patients like face-to-face contact with the case managers and individual help in managing their conditions, and the case managers have a high degree of job satisfaction.
"Initially, when the concept came about, our case management staff were somewhat tentative. Now that we're hearing great success stories, there's a lot of excitement about the idea of the medical home," Schlude says.
Following the success of a 30-month pilot project with three primary care practices, Capital District Physicians' Health Plan (CDPHP) has expanded its medical home initiative to include an additional 21 physician practices.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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